Dental Forms

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Dental Patient Health History Forms

Below are the dental forms and dental consent forms we use in easy to download and print format.  Many of our patients prefer to fill these out at home and simply bring them to their appointment.  We have found that this is less stressful and more streamlined for our patients and that it makes for a less hectic and more enjoyable dental visit.   

If you are a new patient, please download and print the Health History forms, Insurance, Notice of Private Practice, Private Practice Acknowledgment forms listed below.  Please go to our Contact Us page for a mailing address or Fax to the following numbers:

  • Downtown: (816) 421-0356
  • Independence: (816) 795-6732
  • Plaza: (816) 531-0559

 Please follow up your fax to confirm receipt of forms - thank you

Health History: docs/New patient form.docx

 

Insurance: docs/Update Insurance Form.pdf

 

Notice of Private Practice: docs/NOTICE OF PRIVACY PRACTICES-copy.pdf

 

Private Practice Acknowledgment: docs/Privacy Practice Acknowledgement-copy.pdf

 

Apply Today for Care Credit: www.carecredit.com

 

If you are transferring to another dental office, please download and print the Copy of Patient Record Request form below.

 

Copy of Patient Record Request: docs/Copy of Patient Records Request Form.xls

 

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